GI/GU: Monitoring fluid intake and output

Normally, the amount of total body water should be balanced through the ingestion and elimination of water: ins and out.

To ensure this balance, as a nursing assistant, you may need to track and record all fluid intake and output on an intake and output sheet, commonly known as I&O sheet.

This is particularly important for certain groups of clients, like those on special fluid orders, including “encourage fluids” and “restrict fluids;” those who are at risk of developing dehydration, or losing too much body fluid, which impairs normal body functions; or those who might develop edema where swelling occurs in tissues due to excess fluid build up.

High risk of dehydration exists for those who may not be drinking an adequate amount of fluids throughout the day or those who might be losing too much due to receiving certain medications, like diuretics, or through vomiting, diarrhea, bleeding, burns, excessive sweating, fever, or vigorous exercise.

Common signs include dry mouth, excessive thirst, and dark urine. Likewise, clients at risk of developing edema include those receiving intravenous fluids or those with heart or kidney disease, where the body has trouble eliminating excess fluid.

The fluid builds up and causes swelling, especially in the lower extremities. Nursing assistants should check with nurses in charge of the client and the nursing plan of care to find out if the client's intake and output should be monitored.

So, every time one of these clients receives or loses fluids in any way, the exact volume can be recorded. These volumes are then totaled at the end of every shift and then at the end of a 24-hour period.

Okay, so for fluid intake, you’ll need to count anything the client drinks, including water and beverages as well as all foods that are liquid at room temperature, like ice cream, gelatin, sherbert, pudding, custard, ice chips, and popsicles.

The nurse will also measure the fluids provided through intravenous therapy, enteral, or total parenteral nutrition. Now, the unit typically used to measure fluid intake is 1 milliliter, or mL for short.

But some containers use different units, so you may need to be able to make the appropriate conversions. 1 milliliter equals 1 cubic centimeter, or cc for short, and 0.001 liters, or L for short.

1 fluid ounce can get converted into 30 milliliters. And 1 pint is approximately 500 milliliters, whereas 1 quart is about 1,000 milliliters.

It’s also important to know the usual serving sizes in your facility. As a rule of thumb, 1 teaspoon typically contains 5 milliliters; 1 tablespoon, 15 milliliters; and 1 cup, 250 milliliters.

But for the rest of them, like mugs, glasses, or bowls, the volume of fluid contained may vary.So, keeping in mind any necessary conversions, gather the supplies you’ll need, including gloves and a graduated measuring container.

You can then add all fluid volumes served to that client. For example, during your shift, the client could have been served with 200 milliliters of water, 360 milliliters of soda, and 140 milliliters of milk.

All together, these equal 700 milliliters. But it’s possible that the client hasn’t finished all of them.

So, you now need to wear your gloves and transfer whatever has remained from each liquid into a graduated measuring container.

Remember to keep the graduate even and at eye level to ensure precise measurements. So, if the volume left in the graduate is 80 milliliters, this has to be subtracted from the full serving amount of 700 milliliters, giving us a total fluid intake of 620 milliliters.

Finally, remove your gloves and practice hand hygiene.Now, when it comes to fluid output, this includes urine, vomitus, wound drainage, diarrhea, and blood.

Special precautions are required for certain clients, like those undergoing chemotherapy since their urine, stool, and vomit can contain the chemotherapy agent.

Once again, your supplies include gloves and a graduated container. If there’s a possibility of splashing, make sure to also include personal protective equipment, such as a gown, goggles or face shield, and a mask.

These clients need to be provided with urine receptacles specifically labeled with their name and bed location. They should then be specifically told to only urinate in these receptacles and notify you when they are finished before discarding the contents.

Commonly used urine receptacles are specimen “hats” that can be positioned under the toilet seat or a bedside commode to collect urine.

Now, most receptacles already have volume marks. But if the client is using a bedpan or catheter drainage bag, their contents should be emptied into a graduated container.

If the client also vomits, it can be collected in an emesis basin. Blood and wound drainage might be collected in drainage pouches.

If they don’t have volume marks, pour the contents of both emesis basins and drainage pouches into a graduate. Next, hold the receptacle or graduate at eye level to measure the fluid volume.

Afterwards, empty the contents into the toilet and clean, rinse, and disinfect both the receptacles or graduate as well as the toilet.

Keep in mind, though, that if there are fluid losses outside of containers, the nurse will be called to assess the volume.

This could be the case if a client has vomited out of the emesis basin, if there’s blood or wound drainage not contained in a drainage pouch, as well as in the case of diarrhea.

Finally, you can remove your gloves and practice hand hygiene.Now when measuring a client's fluid intake and output, it’s also important to recognize signs, symptoms, or situations where you should notify the nurse immediately.

These include changes in the usual amount of intake; for example, a client refusing to drink the served fluids, as well as changes in the color, clarity, or odor of the output.

Also be sure to report if the intake and output is not balanced. Next, remember to notify the nurse if you observe edema, especially in the lower extremities, or signs of dehydration such as dark urine or a dry mouth.

After that, document the date and time as well as your observations and the measured amounts of fluid intake and output on the client’s paper or electronic I&O record.

A typical I&O sheet has a column with time and two separate sections for intake and output. Intake is then divided into oral intake, which you’ll need to fill with the amount you measured, and parenteral intake, where the nurse will add fluid intake coming from intravenous therapy, enteral, or total parenteral nutrition.

Next, for the output, there’s usually one section for urine and one for everything else. You need to document the amount measured as well as how the fluid was collected, such as through voiding or a urinary catheter.

Make sure all amounts are in milliliters.Alright, as a quick recap… Monitoring fluid intake and output is ordered to evaluate fluid balance in clients with special fluid orders and those at risk of dehydration or edema.

Intake includes all drinks the client has had plus foods that are liquid at room temperature. You should add these up, collect what’s left in a graduate, and subtract that from the full serving amount.

For fluid output, urine, vomitus, wound drainage, diarrhea, and blood amounts are measured. After every procedure, remember to report any unusual signs or symptoms to the nurse and document the amounts measured in the client’s I&O record along with your observations.